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Setting priorities in primary health care - on whose conditions? A questionnaire study

Setting priorities in primary health care - on whose conditions? A questionnaire study Background: In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. Methods: Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. Results: Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. Conclusions: The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria. Background in 1995 [9]. The Swedish parliament ratified the Com- Priority setting is necessary in every part of the health mission’s proposal in 1997 [10]. One stipulation was that care system where needs and demands exceed resources. priority setting should be transparent, i.e. the general Priority setting takes place both at an aggregated na- public should have access to both the results of priority tional or regional level and at an individual clinical level setting decisions and the grounds for them [9,11,12]. All [1-4]. Priority setting in primary health care (PHC) is priority setting should be governed by three ethical prin- important because outcomes from PHC have significant ciples: the human dignity principle, the needs and soli- implications for health care costs and outcomes in the darity principle, and the cost-effectiveness principle. The health system as a whole [5]. Government’s bill established that “The relevant issue in Different approaches for priority setting in PHC have prioritisation is that human dignity is not tied to a per- been proposed [6-8]. In Sweden, the Government son’s personal characteristics or functions in society, but launched a Parliamentary Commission on priority set- to existence itself. It is important to establish that talent, ting in health care, and their final report was published social position, income, age, etc. should not determine who should receive care, or the quality of care” [9]. Hence, the human dignity principle does not tell us how * Correspondence: eva.arvidsson@ltkalmar.se to prioritise, but rather what aspects we are not allowed Department of Medical and Health Sciences, National Centre for Priority to consider. In that respect the human dignity principle Setting in Health Care, Linköping University, Linköping, Sweden Department of Primary Health Care, County Council of Kalmar, Kalmar, is applicable in all types of prioritisation situations. To Sweden operationalise the principles for practical use, the needs Full list of author information is available at the end of the article © 2012 Arvidsson et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 2 of 8 http://www.biomedcentral.com/1471-2296/13/114 and solidarity principle and the cost-effectiveness aim was to study prioritising of individual patients in principle have been transformed into three key criteria: routine primary care. severity of the health condition; patient benefit; and cost- effectiveness of the medical intervention [11]. The rela- Aims tion between the ethical principles and the criteria, and To describe and analyse: the variables that should be considered in appraising each criterion, are schematically described in Figure 1. 1) How general practitioners (GPs), nurses, and patients The three criteria are used for priority setting both na- set priorities in routine primary health care (PHC). tionally and regionally in Sweden [13-15]. Several coun- 2) The association between three key priority setting tries with publicly financed health care systems use criteria and the overall priority assigned by the GPs similar criteria [16,17]. and nurses to individual patients. In an earlier study we found that PHC staff viewed the three key priority setting criteria as useful [18]. The Methods study also indicated that the key priority criteria were We conducted the study during a 2-week period in 2004 used differently depending on whether patients had an at four PHCCs in southern Sweden. Paired question- acute or chronic condition. naires were answered by the patients and GPs or nurses However, values in society and in health care are chan- for every patient who contacted (visit or telephone call) ging worldwide. Patients want to influence their own the PHCC concerning health problems during the study care, both at an individual and a comprehensive level. period. They tend to regard health services more as a commod- ity and have rising expectations and demands on accessi- Settings and participants bility [19]. In Sweden this coincides with a new funding The PHCCs were chosen through purposive sampling. system for PHC where taxes fund primary health care They were located in areas with different populations as centres (PHCCs) in proportion to the number of regards age and social factors. In total, around 25 000 patients linked to the health centre. Hence, at their dis- patients were served by the four PHCCs. cretion, patients can affect resource allocation by chan- Paired questionnaires were given to all patients (parent ging PHCC. (Table 1 lists characteristics of Swedish or guardian of children) who were in contact with the primary health care). This creates tension between the PHCCs regarding a health problem during the study need for the medical staff to economise, the obligation period, and to the staff they were in contact with. Patients to follow guidelines and the need to satisfy the patients’ who had telephone contact received and answered the requests. It is challenging for PHC to balance patients’ questionnaire by mail. In total 3821 patient contacts demands with the expanding need for preventive care of were registered. The staff returned 3679 questionnaires chronic conditions. (96%), and patients returned 2150 (56%). Written consent Since we found no empirical study addressing priority was obtained according to the Swedish Act (2003:460) on setting by patients and staff in primary health care, our Ethics Review of Research. From the 2150 patient Human Dignity Principle Needs and solidarity Principle Cost-effectiveness Principle Severity level of a health Patient benefit/effects of Cost-effectiveness of condition the intervention intervention Current health condition Effects on current health Direct costs - suffering - health service condition - functional impairment interventions, - suffering - quality of life - functional impairment - other measures, e.g. travel - quality of life D Risk for - premature death Effects on risk Indirect costs - disability/continued - premature death suffering - disability/continued - lower quality of life suffering … in relation to - lower quality of life benefit of the Risk for side effects and intervention severe complications from intervention Prevention Diagnostics Treatment Rehabilitation Figure 1 Schematic description of the key components to be considered in Swedish priority setting [11]. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 3 of 8 http://www.biomedcentral.com/1471-2296/13/114 Table 1 Characteristics of Swedish primary health care Financing and Most of the primary health care centres are publicly owned and publicly financed through taxes. ownership GPs and consultation Five years of specialist training is required. About 20% of all specialists are GPs. Three consultations with a specialist per inhabitant and year is average; half of these are with a GP. Consultations with GPs are, on average, 20 minutes. Work organisation Teamwork dominates. GPs work in close collaboration with district nurses and other health care personnel. Most appointments with the PHCC are preceded by a telephone call to a nurse who decides whether to schedule the patient to see a GP, a nurse, or whether advice by telephone will be sufficient. questionnaires we identified 1851 matched pairs with one consensus. The acute/minor group consisted of acute con- questionnaire from staff and one from a patient concern- ditions and minor and time-limited health problems in- ing the same contact. Table 2 lists basic characteristics volving minor signs and symptoms, e.g. mild infections of the consultations. The 299 non-matched patient ques- and minor injuries with little or no medical impact from tionnaires were largely due to errors in coding of the medical interventions. The chronic stable group included questionnaires, which made matching impossible. In check-ups for chronic stable conditions that were at risk some cases the reason was that questionnaires from staff for future complications, e.g. heart failure, diabetes, COPD, were missing. and atrial fibrillation. Health conditions and interventions that we excluded were acute conditions requiring treat- ment or further diagnostic procedures, e.g. infections such Questionnaires as pneumonia or upper urinary tract infection, exacerba- The questionnaires were pretested at two of the partici- tion of chronic conditions, and long-lasting conditions pating health centres, and minor adjustments were made with no or little risk for future complications (Table 3). before the study. First, staff registered the health prob- lem or condition that was the main reason for the visit Data analysis and statistics and the related intervention or measure (e.g. further in- Data from the matched questionnaires (n=1851) were vestigation, medical treatment, or health advice). Second, analysed in comparing priority setting by staff and they used a 3-point rating scale (high, moderate, or low) patients. When analysing staff's use of the criteria we used to estimate the severity of the health condition, the all of the staff's questionnaires (n=3679, Table 4). We used expected patient benefit of the planned intervention, and paired Student’s t-test to determine the relation between the cost-effectiveness of the planned intervention. patients’ and staff’s priority setting. Multiple regression Finally, using a 10-point scale they assigned an overall analysis was used to study the relationship between the priority to the patient by answering the question: How overall prioritisation (dependent variable) and the priority would you prioritise the patient on a scale of 1 to 10, setting criteria (independent variables). where 1 is the highest? To examine if the type of consultation, i.e. acute/minor The patients used a similar10-point rating scale to es- or chronic stable, affected the impact of each of the three timate their own overall priority by answering the ques- different priority setting criteria on overall priority setting, tion: How important do you think your health care needs the regression models included interactions between the are compared to other patients? predictors and type of consultation. All other two-way interactions were also examined. We made estimates Groups of health conditions using robust standard errors. Two senior GPs (EA and MA) independently sorted out All independent variables were tested for multicollinear- two subgroups from all registered health conditions and ity by examining their Variance Inflation Factor (VIF). VIF interventions. Disagreements were resolved through values ≥ 2.5 were considered to indicate multicollinearity. For all calculations both the 10-point scale and the 3-point scale were used in "the same direction" (the lower Table 2 Basic characteristics of the consultations, N=1851(%) number, the higher estimation of priority and severity/ GP Nurse benefit/cost-effectiveness). Type of contact Visits 32 27 The Research Ethics Committee of Linköping Univer- Telephone 734 sity approved this study. Patient age 65 or less 28 33 Results Over 65 11 28 Comparison between patients and medical staff Patient gender Women 22 37 When comparing the patient’s overall priority of the health Men 17 24 condition and intervention (or intended intervention), Arvidsson et al. BMC Family Practice 2012, 13:114 Page 4 of 8 http://www.biomedcentral.com/1471-2296/13/114 Table 3 Examples of health problems and related interventions included and not included in the analysis Acute/minor (n=343) Chronic/stable (n=223) Not included (n=1285) Conjunctivitis Hypothyreosis without symptoms Pneumonia or suspected pneumonia Advice and possible medical treatment Check up of medical treatment Examination and treatment with antibiotics Sore throat, fever below 38.5 COPD, patient smokes Advice by telephone Check up, advice on smoking cessation Suspected ischemic heart disease, not acute Mild abdominal pain Examination, and possible further investigation and medical treatment Advice by telephone Type 2 diabetes mellitus with complications Myalgia or tendinitis, short duration Check-up, intensified treatment, possible Eczema treatment of complications Examination and treatment Examination and possible medical treatment or Atrial fibrillation, risk factors for thrombosis Osteoarthritis (hip or knee) referral to physiotherapist Anticoagulant therapy Training instructions, medical treatment with the GP’sornurse’s priority of the same clinical situ- and patient benefit (Table 4). When analysing GPs and ation, we found that patients in general assigned a higher nurses separately, we found that the criterion that had priority than staff did, especially for acute/minor condi- the strongest association with the overall prioritisation tions (Table 5). The acute/minor conditions comprised for the GPs was cost-effectiveness. For the nurses it was 21% of all contacts, and chronic stable comprised 12%. severity of the health condition. The greatest difference was found between GPs and An interaction analysis showed an interaction between patients for acute/minor conditions, where the mean dif- the severity of the condition and the cost-effectiveness ference was 1.33. The most frequently registered acute/ of the intervention for GPs. If both were scored low, minor condition and intervention was upper respiratory then the overall priority was not as low as it would have tract infection and medical examination and advice.The been without the interaction effect. mean overall rating of these patients on the 10-point scale Interactions between type of condition and the inde- (with 1 being the highest priority and 10 the lowest) was pendent variables were tested to determine if the three 8.1 by GPs and 5.6 by patients. key criteria were weighted differently depending on One of the most frequently registered chronic condi- whether the condition was acute/minor or chronic stable. tions and interventions was yearly check-up for ischemic Only one interaction was found. For nurses, patient heart disease where the mean ratings were 4.1 by GPs benefit was more important if the patient had a chronic and 4.6 by patients. stable condition rather than an acute/minor one. Use of priority setting criteria Discussion The estimations of the three key criteria were associated The central finding was that patients, compared to med- with the overall prioritisation of each patient; the coeffi- ical staff, gave higher priority to acute/minor conditions cient of determination 0.54 was for GPs and 0,40 for than to chronic conditions and preventive measures nurses (Table 4). In the multiple regression analysis, when they prioritised individual patients in routine pri- when analysing GPs and nurses together, severity of the mary care. Of the three criteria used by the staff in pri- health condition was the priority setting criterion that ority setting, the severity of the health condition had the had the strongest association with their overall priori- strongest association with overall priority. For GPs alone tisation of the patients, followed by cost-effectiveness cost-effectiveness had the strongest association. Table 4 Multiple regression analyses on prioritisation for all staff, GPs and nurses All staff β (95% CI) GPs β (95% CI) Nurses β (95% CI) Severity of the health condition 1.18 (1.09-1.28) 1.03 (0.88 - 1.19) 1.25 (1.14 - 1.36) Patient benefit 0.70 (0.59-0.80) 0.68 (0.50 - 0.86) 0.68 (0.54 - 0.82) Cost-effectiveness 0.74 (0.64-0.84) 1.12 (0.94 - 1.30) 0.54 (0.42 - 0.66) n 3679 1489 2190 R 0.45 0.54 0.40 All independent variables had VIF values below 2.5. P<0.0001 for all explanatory variables. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 5 of 8 http://www.biomedcentral.com/1471-2296/13/114 Table 5 Overall prioritisation of common health conditions by patients and staff (paired t-test, means) n Staff Patients Difference (95% CI) p All health problems All staff 1851 5.53 4.75 0.79 (0.65−0.92) p=<.0001 GPs 718 5.69 4.63 1.05 (0.84−1.26) p=<.0001 Nurses 1133 5.43 4.82 0.62 (0.44−0.79) p=<.0001 Acute/minor health conditions GPs 169 6.02 4.69 1.33 (0.91−1.76) p=<.0001 Nurses 174 6.02 4.83 1.19 (0.74−1.64) p=<.0001 Chronic stable health conditions GPs 84 4.76 4.82 −0.06 (−0.63−0.51) p=0.835 Nurses 139 5.67 5.01 0.65 (0.19−1.12) p=0.006 Comparison between patients and medical staff found cost-effectiveness difficult to understand and This initial study of prioritisation of individual patients apply [25,26]. Formal health economic evaluations are in routine care in general practice indicates that GPs, seldom available for health conditions and interventions nurses, and patients hold different opinions on what common in primary care. In one study, GPs described type of health conditions and interventions should re- how they tried to make a rough estimate of cost- ceive highest priority. GPs generally gave higher priority effectiveness to use as a basis for priority setting [27]. to patients with chronic stable conditions where the Our previous study found that GPs and nurses made an focus was on trying to prevent future complications, assessment of anticipated benefits or cost-effectiveness while patients gave the highest priority to acute/minor for the individual patient by thinking of a group of simi- health problems. An earlier study showed that patients lar patients [18]. in PHC have high expectations on the health service to Nevertheless, cost-effectiveness was the criterion hav- meet all of their demands, including health care for triv- ing the greatest influence on overall priority for the GPs. ial problems [20]. Different opinions between GPs and This contrasts with the original proposal from the Prior- patients on what is most important have also been found ities Commission, which ranked the cost-effectiveness in other studies [21,22]. This disagreement between principle as the lowest of the three ethical principles. needs as defined by patients and by physicians might be According to the Commission, the cost-effectiveness explained by their different viewpoints; for GPs medical principle should be applied only when comparing meth- knowledge is an important factor in the priority setting ods of treatment for the same disease, since the effects process. Even if the GPs also consider factors other than cannot otherwise be compared in an equitable way. biomedical criteria they emphasise the medical perspec- However, the Government states in its bill “.. .it is essen- tive in priority setting [18,23,24]. In our earlier study the tial to differentiate between the cost-effectiveness of a GPs acknowledged the medical, evidence-based, perspec- treatment for a particular individual and that for health tive concerning the effect of secondary prevention in care at large. A cost-effectiveness principle that concerns chronic stable conditions compared to interventions in choices between different interventions for the individ- self-limiting disorders [18]. This might explain the high ual patient must be applied as proposed by the inquiry, priority given to check-ups of patients with chronic con- and is subordinated to the principles of human dignity ditions. It seems to be reasonable that patients are more and needs and solitary. Nevertheless, it is essential for influenced by their present symptoms than by the future health services to strive for high cost-effectiveness as risk of complications. regards health care services in general” [9]. Here the Gov- ernment indicates a different rank of cost-effectiveness in priority setting between the individual and group levels. In Use of priority setting criteria practical use, e.g. by the Swedish National Board of Health The association between the three key criteria and the overall priority indicates that the criteria largely influ- and Welfare and the Dental and Pharmaceutical Benefits Agency, cost-effectiveness plays a central role in writing enced the overall prioritisation of each patient, for both national guidelines for priority setting and in decisions the GPs and the nurses, which confirms the results from our earlier study where the GPs and nurses regarding which pharmaceuticals the state will subsidise. Still, we have little information about how the priority set- reported that the criteria were useful in day-to-day ting principles are actually applied at the individual level. It priority setting [18]. Use of the three criteria, especially cost-effectiveness, is possible that the new Swedish funding system have increased cost awareness among GPs since PHCCs have differed between doctors and nurses in their overall pri- local responsibility for a limited budget that must cover oritisation. Other studies show that nurses and GPs Arvidsson et al. BMC Family Practice 2012, 13:114 Page 6 of 8 http://www.biomedcentral.com/1471-2296/13/114 everything, including drugs, for their patients [28]. GPs are subjective judgements where responders have some also becoming more familiar with economic evaluations doubts about “proper” answers [33]. In our study this es- through the national guidelines on priority setting [29]. pecially applied to patients who often responded around Patient benefit had the least influence on the GPs’ the mid-point of the priority scale. This central tendency overall priority. This contrasts to another study concern- bias might have affected the result so that differences in ing prioritisation of new technology by committees prioritising, measured in scale-points, can be relatively where the general public, patients, health professionals, small. Hence, the direction of the differences, or the re- and administrators participated. In this study, patient lation between ratings, might be more interesting than benefit was the most important factor for decisions [30]. the actual numbers. Patient benefit is a subset of cost-effectiveness. However, The staff were supposed to fill in the questionnaire dir- in this study multicollinearity of the predictors in the re- ectly after each consultation. We selected a simple three- gression analysis was negative, implying no association. step ordinal scale to make the study feasible in day-to-day For nurses, cost-effectiveness was the least important care. Both the 10- and the 3-point scales used in this study criteria. In a focus group, nurses in the study said they are used in Sweden on the national and regional levels for did not want to think about the costs of health care at priority setting. In recent years, 4-point scales have been all [18]. However, the nurses evaluated patient benefit as used. Since it is difficult to find objective mathematical or more important for patients with chronic stable condi- quantitative methods to calculate priority levels, qualitative tions than for patients with acute/minor conditions. estimations are usually used [11,34,35]. Severity is a familiar concept in routine PHC work and The rating on the 3-point scales was introduced in the is used as an established criterion for priority setting also regression model as an interval scale since the variables in other countries [16,17]. For the GPs in our study, esti- had a linear approximation with our dependent variable. mated severity had a slightly smaller effect on overall Introducing the variables with dummy coding made neg- priority than cost-effectiveness, and for the nurses sever- ligible differences in the results. ity influenced overall priority much more than the other The lack of association between patient benefit and two criteria. cost-effectiveness found in this study, suggests that pa- tient benefit and cost-effectiveness were seen as distinct Strengths and limitations from each other by the staff. It is possible that the staff The response rate from staff was high (96%). However, did not fully understand the concept of cost-effective- the lower response rate from the patients (56%) was ness, but mixed it up with costs per se. considered to be acceptable. Similar rates have been As organisational characteristics and professional roles reported in comparable types of studies, and moreover in PHC differ between countries, some of the findings response rates in questionnaire studies are generally de- might be context-bound to Sweden. Since this might be clining [21,31]. Responders and non-responders did not a limitation of the study, further studies are needed in differ concerning age and gender, but telephone contacts other settings. were higher among the non-responders. We do not know if this affected the results. Health policy implications The large number of observations is a strength of this The results of this study of individual patients may have study. However, despite over 1800 complete pairs of implications for development of priority setting in PHC observations, the frequency of each specific health con- at the national or regional level. The high influence that dition and intervention was low due to the wide vari- GPs gave cost-effectiveness in their priority setting might ation of health problems in primary care [32]. influence prioritising and rationing for individual patients A weakness is the lack of an established classification in day-to-day primary care in a different way than the policy system for health problems and related interventions. makers originally intended. The two groups, a) acute/minor time limited conditions Comprehensiveness, continuity, and person-centredness and interventions and b) chronic stable conditions with are essential to better health outcomes in PHC. Close and a risk for future complications, may be defined differ- trusting relationships with GPs and nurses who know ently. What the groups include or exclude is not clearly their patients are critical for a well-functioning PHC [19]. specified. To make the groups as well-defined as pos- There is ample evidence that continuity of care in PHC sible, we included only typical conditions. contributes both to better quality of care and better out- Comparison of estimated values on an ordinal scale comes [36,37]. Early detection and prevention of problems can cause problems. First, the scales are subjective and are facilitated. Furthermore, episodes of care that begin different persons may interpret them differently, which with visits to an individual’s primary care clinician, as can make comparisons hazardous. Second, there is a opposed to other sources of care, are associated with sig- tendency to avoid using the ends of the scales in nificantly lower costs [38]. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 7 of 8 http://www.biomedcentral.com/1471-2296/13/114 Also, single consultations for minor problems might Authors’ contributions EA, MA, LB and PC planned the study. EA conducted the first analysis in yield high patient benefit and cost-effectiveness in the dialogue with all in the research group. DA made the statistical analysis and long term and might therefore be acknowledged by the calculations. All authors performed the final analysis, and were involved in GPs and nurses. On the other hand, there is a risk that drafting the manuscript as well as the final approval of the manuscript. the adaptation of priority setting to the patients’ demands, rather than needs, might influence consump- Acknowledgements tion and funding of health care in an unfair and ineffi- We want to thank FORSS (Council for Research in Southeast Sweden) for funding, and the county councils of Jönköping, Kalmar, and Östergötland, cient way [19]. Without a well-functioning system for and the Faculty of Health Sciences, Linköping University, for supporting the priority setting there is a risk that preventive care for study. We also thank each of the patients, nurses, and GPs who participated chronic conditions with few overt symptoms gets forced in this study. out in favour of minor self-limiting problems. In recent Author details years, the Swedish government has focused on accessi- Department of Medical and Health Sciences, National Centre for Priority bility in health care. National figures are presented regu- Setting in Health Care, Linköping University, Linköping, Sweden. Department of Primary Health Care, County Council of Kalmar, Kalmar, larly on the number of days patients must wait for an Sweden. Department of Public Health and Caring Sciences - Family appointment in primary care. Trends indicate that the Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden. number of visits are increasing and waiting times are de- Department of Medical and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden. Department of Management and creasing. This, in combination with the new Swedish Engineering, Division of Economics, Linköping University, Linköping, Sweden. funding system for primary care – where patients direct and redirect funds by their choice of PHCC – might Received: 17 May 2012 Accepted: 15 November 2012 Published: 26 November 2012 make prioritising according to ethical principles difficult. For instance, a study indicated that waiting-time guaran- tees led health care providers to give priority to access References rather than needs for care [39]. 1. Carlsson P: Priority setting in health care: Swedish efforts and experiences. Scand J Public Health 2010, 38(6):561–564. The challenge for primary care providers is to balance 2. 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Setting priorities in primary health care - on whose conditions? A questionnaire study

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Copyright © 2012 by Arvidsson et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. Methods: Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. Results: Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. Conclusions: The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria. Background in 1995 [9]. The Swedish parliament ratified the Com- Priority setting is necessary in every part of the health mission’s proposal in 1997 [10]. One stipulation was that care system where needs and demands exceed resources. priority setting should be transparent, i.e. the general Priority setting takes place both at an aggregated na- public should have access to both the results of priority tional or regional level and at an individual clinical level setting decisions and the grounds for them [9,11,12]. All [1-4]. Priority setting in primary health care (PHC) is priority setting should be governed by three ethical prin- important because outcomes from PHC have significant ciples: the human dignity principle, the needs and soli- implications for health care costs and outcomes in the darity principle, and the cost-effectiveness principle. The health system as a whole [5]. Government’s bill established that “The relevant issue in Different approaches for priority setting in PHC have prioritisation is that human dignity is not tied to a per- been proposed [6-8]. In Sweden, the Government son’s personal characteristics or functions in society, but launched a Parliamentary Commission on priority set- to existence itself. It is important to establish that talent, ting in health care, and their final report was published social position, income, age, etc. should not determine who should receive care, or the quality of care” [9]. Hence, the human dignity principle does not tell us how * Correspondence: eva.arvidsson@ltkalmar.se to prioritise, but rather what aspects we are not allowed Department of Medical and Health Sciences, National Centre for Priority to consider. In that respect the human dignity principle Setting in Health Care, Linköping University, Linköping, Sweden Department of Primary Health Care, County Council of Kalmar, Kalmar, is applicable in all types of prioritisation situations. To Sweden operationalise the principles for practical use, the needs Full list of author information is available at the end of the article © 2012 Arvidsson et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 2 of 8 http://www.biomedcentral.com/1471-2296/13/114 and solidarity principle and the cost-effectiveness aim was to study prioritising of individual patients in principle have been transformed into three key criteria: routine primary care. severity of the health condition; patient benefit; and cost- effectiveness of the medical intervention [11]. The rela- Aims tion between the ethical principles and the criteria, and To describe and analyse: the variables that should be considered in appraising each criterion, are schematically described in Figure 1. 1) How general practitioners (GPs), nurses, and patients The three criteria are used for priority setting both na- set priorities in routine primary health care (PHC). tionally and regionally in Sweden [13-15]. Several coun- 2) The association between three key priority setting tries with publicly financed health care systems use criteria and the overall priority assigned by the GPs similar criteria [16,17]. and nurses to individual patients. In an earlier study we found that PHC staff viewed the three key priority setting criteria as useful [18]. The Methods study also indicated that the key priority criteria were We conducted the study during a 2-week period in 2004 used differently depending on whether patients had an at four PHCCs in southern Sweden. Paired question- acute or chronic condition. naires were answered by the patients and GPs or nurses However, values in society and in health care are chan- for every patient who contacted (visit or telephone call) ging worldwide. Patients want to influence their own the PHCC concerning health problems during the study care, both at an individual and a comprehensive level. period. They tend to regard health services more as a commod- ity and have rising expectations and demands on accessi- Settings and participants bility [19]. In Sweden this coincides with a new funding The PHCCs were chosen through purposive sampling. system for PHC where taxes fund primary health care They were located in areas with different populations as centres (PHCCs) in proportion to the number of regards age and social factors. In total, around 25 000 patients linked to the health centre. Hence, at their dis- patients were served by the four PHCCs. cretion, patients can affect resource allocation by chan- Paired questionnaires were given to all patients (parent ging PHCC. (Table 1 lists characteristics of Swedish or guardian of children) who were in contact with the primary health care). This creates tension between the PHCCs regarding a health problem during the study need for the medical staff to economise, the obligation period, and to the staff they were in contact with. Patients to follow guidelines and the need to satisfy the patients’ who had telephone contact received and answered the requests. It is challenging for PHC to balance patients’ questionnaire by mail. In total 3821 patient contacts demands with the expanding need for preventive care of were registered. The staff returned 3679 questionnaires chronic conditions. (96%), and patients returned 2150 (56%). Written consent Since we found no empirical study addressing priority was obtained according to the Swedish Act (2003:460) on setting by patients and staff in primary health care, our Ethics Review of Research. From the 2150 patient Human Dignity Principle Needs and solidarity Principle Cost-effectiveness Principle Severity level of a health Patient benefit/effects of Cost-effectiveness of condition the intervention intervention Current health condition Effects on current health Direct costs - suffering - health service condition - functional impairment interventions, - suffering - quality of life - functional impairment - other measures, e.g. travel - quality of life D Risk for - premature death Effects on risk Indirect costs - disability/continued - premature death suffering - disability/continued - lower quality of life suffering … in relation to - lower quality of life benefit of the Risk for side effects and intervention severe complications from intervention Prevention Diagnostics Treatment Rehabilitation Figure 1 Schematic description of the key components to be considered in Swedish priority setting [11]. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 3 of 8 http://www.biomedcentral.com/1471-2296/13/114 Table 1 Characteristics of Swedish primary health care Financing and Most of the primary health care centres are publicly owned and publicly financed through taxes. ownership GPs and consultation Five years of specialist training is required. About 20% of all specialists are GPs. Three consultations with a specialist per inhabitant and year is average; half of these are with a GP. Consultations with GPs are, on average, 20 minutes. Work organisation Teamwork dominates. GPs work in close collaboration with district nurses and other health care personnel. Most appointments with the PHCC are preceded by a telephone call to a nurse who decides whether to schedule the patient to see a GP, a nurse, or whether advice by telephone will be sufficient. questionnaires we identified 1851 matched pairs with one consensus. The acute/minor group consisted of acute con- questionnaire from staff and one from a patient concern- ditions and minor and time-limited health problems in- ing the same contact. Table 2 lists basic characteristics volving minor signs and symptoms, e.g. mild infections of the consultations. The 299 non-matched patient ques- and minor injuries with little or no medical impact from tionnaires were largely due to errors in coding of the medical interventions. The chronic stable group included questionnaires, which made matching impossible. In check-ups for chronic stable conditions that were at risk some cases the reason was that questionnaires from staff for future complications, e.g. heart failure, diabetes, COPD, were missing. and atrial fibrillation. Health conditions and interventions that we excluded were acute conditions requiring treat- ment or further diagnostic procedures, e.g. infections such Questionnaires as pneumonia or upper urinary tract infection, exacerba- The questionnaires were pretested at two of the partici- tion of chronic conditions, and long-lasting conditions pating health centres, and minor adjustments were made with no or little risk for future complications (Table 3). before the study. First, staff registered the health prob- lem or condition that was the main reason for the visit Data analysis and statistics and the related intervention or measure (e.g. further in- Data from the matched questionnaires (n=1851) were vestigation, medical treatment, or health advice). Second, analysed in comparing priority setting by staff and they used a 3-point rating scale (high, moderate, or low) patients. When analysing staff's use of the criteria we used to estimate the severity of the health condition, the all of the staff's questionnaires (n=3679, Table 4). We used expected patient benefit of the planned intervention, and paired Student’s t-test to determine the relation between the cost-effectiveness of the planned intervention. patients’ and staff’s priority setting. Multiple regression Finally, using a 10-point scale they assigned an overall analysis was used to study the relationship between the priority to the patient by answering the question: How overall prioritisation (dependent variable) and the priority would you prioritise the patient on a scale of 1 to 10, setting criteria (independent variables). where 1 is the highest? To examine if the type of consultation, i.e. acute/minor The patients used a similar10-point rating scale to es- or chronic stable, affected the impact of each of the three timate their own overall priority by answering the ques- different priority setting criteria on overall priority setting, tion: How important do you think your health care needs the regression models included interactions between the are compared to other patients? predictors and type of consultation. All other two-way interactions were also examined. We made estimates Groups of health conditions using robust standard errors. Two senior GPs (EA and MA) independently sorted out All independent variables were tested for multicollinear- two subgroups from all registered health conditions and ity by examining their Variance Inflation Factor (VIF). VIF interventions. Disagreements were resolved through values ≥ 2.5 were considered to indicate multicollinearity. For all calculations both the 10-point scale and the 3-point scale were used in "the same direction" (the lower Table 2 Basic characteristics of the consultations, N=1851(%) number, the higher estimation of priority and severity/ GP Nurse benefit/cost-effectiveness). Type of contact Visits 32 27 The Research Ethics Committee of Linköping Univer- Telephone 734 sity approved this study. Patient age 65 or less 28 33 Results Over 65 11 28 Comparison between patients and medical staff Patient gender Women 22 37 When comparing the patient’s overall priority of the health Men 17 24 condition and intervention (or intended intervention), Arvidsson et al. BMC Family Practice 2012, 13:114 Page 4 of 8 http://www.biomedcentral.com/1471-2296/13/114 Table 3 Examples of health problems and related interventions included and not included in the analysis Acute/minor (n=343) Chronic/stable (n=223) Not included (n=1285) Conjunctivitis Hypothyreosis without symptoms Pneumonia or suspected pneumonia Advice and possible medical treatment Check up of medical treatment Examination and treatment with antibiotics Sore throat, fever below 38.5 COPD, patient smokes Advice by telephone Check up, advice on smoking cessation Suspected ischemic heart disease, not acute Mild abdominal pain Examination, and possible further investigation and medical treatment Advice by telephone Type 2 diabetes mellitus with complications Myalgia or tendinitis, short duration Check-up, intensified treatment, possible Eczema treatment of complications Examination and treatment Examination and possible medical treatment or Atrial fibrillation, risk factors for thrombosis Osteoarthritis (hip or knee) referral to physiotherapist Anticoagulant therapy Training instructions, medical treatment with the GP’sornurse’s priority of the same clinical situ- and patient benefit (Table 4). When analysing GPs and ation, we found that patients in general assigned a higher nurses separately, we found that the criterion that had priority than staff did, especially for acute/minor condi- the strongest association with the overall prioritisation tions (Table 5). The acute/minor conditions comprised for the GPs was cost-effectiveness. For the nurses it was 21% of all contacts, and chronic stable comprised 12%. severity of the health condition. The greatest difference was found between GPs and An interaction analysis showed an interaction between patients for acute/minor conditions, where the mean dif- the severity of the condition and the cost-effectiveness ference was 1.33. The most frequently registered acute/ of the intervention for GPs. If both were scored low, minor condition and intervention was upper respiratory then the overall priority was not as low as it would have tract infection and medical examination and advice.The been without the interaction effect. mean overall rating of these patients on the 10-point scale Interactions between type of condition and the inde- (with 1 being the highest priority and 10 the lowest) was pendent variables were tested to determine if the three 8.1 by GPs and 5.6 by patients. key criteria were weighted differently depending on One of the most frequently registered chronic condi- whether the condition was acute/minor or chronic stable. tions and interventions was yearly check-up for ischemic Only one interaction was found. For nurses, patient heart disease where the mean ratings were 4.1 by GPs benefit was more important if the patient had a chronic and 4.6 by patients. stable condition rather than an acute/minor one. Use of priority setting criteria Discussion The estimations of the three key criteria were associated The central finding was that patients, compared to med- with the overall prioritisation of each patient; the coeffi- ical staff, gave higher priority to acute/minor conditions cient of determination 0.54 was for GPs and 0,40 for than to chronic conditions and preventive measures nurses (Table 4). In the multiple regression analysis, when they prioritised individual patients in routine pri- when analysing GPs and nurses together, severity of the mary care. Of the three criteria used by the staff in pri- health condition was the priority setting criterion that ority setting, the severity of the health condition had the had the strongest association with their overall priori- strongest association with overall priority. For GPs alone tisation of the patients, followed by cost-effectiveness cost-effectiveness had the strongest association. Table 4 Multiple regression analyses on prioritisation for all staff, GPs and nurses All staff β (95% CI) GPs β (95% CI) Nurses β (95% CI) Severity of the health condition 1.18 (1.09-1.28) 1.03 (0.88 - 1.19) 1.25 (1.14 - 1.36) Patient benefit 0.70 (0.59-0.80) 0.68 (0.50 - 0.86) 0.68 (0.54 - 0.82) Cost-effectiveness 0.74 (0.64-0.84) 1.12 (0.94 - 1.30) 0.54 (0.42 - 0.66) n 3679 1489 2190 R 0.45 0.54 0.40 All independent variables had VIF values below 2.5. P<0.0001 for all explanatory variables. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 5 of 8 http://www.biomedcentral.com/1471-2296/13/114 Table 5 Overall prioritisation of common health conditions by patients and staff (paired t-test, means) n Staff Patients Difference (95% CI) p All health problems All staff 1851 5.53 4.75 0.79 (0.65−0.92) p=<.0001 GPs 718 5.69 4.63 1.05 (0.84−1.26) p=<.0001 Nurses 1133 5.43 4.82 0.62 (0.44−0.79) p=<.0001 Acute/minor health conditions GPs 169 6.02 4.69 1.33 (0.91−1.76) p=<.0001 Nurses 174 6.02 4.83 1.19 (0.74−1.64) p=<.0001 Chronic stable health conditions GPs 84 4.76 4.82 −0.06 (−0.63−0.51) p=0.835 Nurses 139 5.67 5.01 0.65 (0.19−1.12) p=0.006 Comparison between patients and medical staff found cost-effectiveness difficult to understand and This initial study of prioritisation of individual patients apply [25,26]. Formal health economic evaluations are in routine care in general practice indicates that GPs, seldom available for health conditions and interventions nurses, and patients hold different opinions on what common in primary care. In one study, GPs described type of health conditions and interventions should re- how they tried to make a rough estimate of cost- ceive highest priority. GPs generally gave higher priority effectiveness to use as a basis for priority setting [27]. to patients with chronic stable conditions where the Our previous study found that GPs and nurses made an focus was on trying to prevent future complications, assessment of anticipated benefits or cost-effectiveness while patients gave the highest priority to acute/minor for the individual patient by thinking of a group of simi- health problems. An earlier study showed that patients lar patients [18]. in PHC have high expectations on the health service to Nevertheless, cost-effectiveness was the criterion hav- meet all of their demands, including health care for triv- ing the greatest influence on overall priority for the GPs. ial problems [20]. Different opinions between GPs and This contrasts with the original proposal from the Prior- patients on what is most important have also been found ities Commission, which ranked the cost-effectiveness in other studies [21,22]. This disagreement between principle as the lowest of the three ethical principles. needs as defined by patients and by physicians might be According to the Commission, the cost-effectiveness explained by their different viewpoints; for GPs medical principle should be applied only when comparing meth- knowledge is an important factor in the priority setting ods of treatment for the same disease, since the effects process. Even if the GPs also consider factors other than cannot otherwise be compared in an equitable way. biomedical criteria they emphasise the medical perspec- However, the Government states in its bill “.. .it is essen- tive in priority setting [18,23,24]. In our earlier study the tial to differentiate between the cost-effectiveness of a GPs acknowledged the medical, evidence-based, perspec- treatment for a particular individual and that for health tive concerning the effect of secondary prevention in care at large. A cost-effectiveness principle that concerns chronic stable conditions compared to interventions in choices between different interventions for the individ- self-limiting disorders [18]. This might explain the high ual patient must be applied as proposed by the inquiry, priority given to check-ups of patients with chronic con- and is subordinated to the principles of human dignity ditions. It seems to be reasonable that patients are more and needs and solitary. Nevertheless, it is essential for influenced by their present symptoms than by the future health services to strive for high cost-effectiveness as risk of complications. regards health care services in general” [9]. Here the Gov- ernment indicates a different rank of cost-effectiveness in priority setting between the individual and group levels. In Use of priority setting criteria practical use, e.g. by the Swedish National Board of Health The association between the three key criteria and the overall priority indicates that the criteria largely influ- and Welfare and the Dental and Pharmaceutical Benefits Agency, cost-effectiveness plays a central role in writing enced the overall prioritisation of each patient, for both national guidelines for priority setting and in decisions the GPs and the nurses, which confirms the results from our earlier study where the GPs and nurses regarding which pharmaceuticals the state will subsidise. Still, we have little information about how the priority set- reported that the criteria were useful in day-to-day ting principles are actually applied at the individual level. It priority setting [18]. Use of the three criteria, especially cost-effectiveness, is possible that the new Swedish funding system have increased cost awareness among GPs since PHCCs have differed between doctors and nurses in their overall pri- local responsibility for a limited budget that must cover oritisation. Other studies show that nurses and GPs Arvidsson et al. BMC Family Practice 2012, 13:114 Page 6 of 8 http://www.biomedcentral.com/1471-2296/13/114 everything, including drugs, for their patients [28]. GPs are subjective judgements where responders have some also becoming more familiar with economic evaluations doubts about “proper” answers [33]. In our study this es- through the national guidelines on priority setting [29]. pecially applied to patients who often responded around Patient benefit had the least influence on the GPs’ the mid-point of the priority scale. This central tendency overall priority. This contrasts to another study concern- bias might have affected the result so that differences in ing prioritisation of new technology by committees prioritising, measured in scale-points, can be relatively where the general public, patients, health professionals, small. Hence, the direction of the differences, or the re- and administrators participated. In this study, patient lation between ratings, might be more interesting than benefit was the most important factor for decisions [30]. the actual numbers. Patient benefit is a subset of cost-effectiveness. However, The staff were supposed to fill in the questionnaire dir- in this study multicollinearity of the predictors in the re- ectly after each consultation. We selected a simple three- gression analysis was negative, implying no association. step ordinal scale to make the study feasible in day-to-day For nurses, cost-effectiveness was the least important care. Both the 10- and the 3-point scales used in this study criteria. In a focus group, nurses in the study said they are used in Sweden on the national and regional levels for did not want to think about the costs of health care at priority setting. In recent years, 4-point scales have been all [18]. However, the nurses evaluated patient benefit as used. Since it is difficult to find objective mathematical or more important for patients with chronic stable condi- quantitative methods to calculate priority levels, qualitative tions than for patients with acute/minor conditions. estimations are usually used [11,34,35]. Severity is a familiar concept in routine PHC work and The rating on the 3-point scales was introduced in the is used as an established criterion for priority setting also regression model as an interval scale since the variables in other countries [16,17]. For the GPs in our study, esti- had a linear approximation with our dependent variable. mated severity had a slightly smaller effect on overall Introducing the variables with dummy coding made neg- priority than cost-effectiveness, and for the nurses sever- ligible differences in the results. ity influenced overall priority much more than the other The lack of association between patient benefit and two criteria. cost-effectiveness found in this study, suggests that pa- tient benefit and cost-effectiveness were seen as distinct Strengths and limitations from each other by the staff. It is possible that the staff The response rate from staff was high (96%). However, did not fully understand the concept of cost-effective- the lower response rate from the patients (56%) was ness, but mixed it up with costs per se. considered to be acceptable. Similar rates have been As organisational characteristics and professional roles reported in comparable types of studies, and moreover in PHC differ between countries, some of the findings response rates in questionnaire studies are generally de- might be context-bound to Sweden. Since this might be clining [21,31]. Responders and non-responders did not a limitation of the study, further studies are needed in differ concerning age and gender, but telephone contacts other settings. were higher among the non-responders. We do not know if this affected the results. Health policy implications The large number of observations is a strength of this The results of this study of individual patients may have study. However, despite over 1800 complete pairs of implications for development of priority setting in PHC observations, the frequency of each specific health con- at the national or regional level. The high influence that dition and intervention was low due to the wide vari- GPs gave cost-effectiveness in their priority setting might ation of health problems in primary care [32]. influence prioritising and rationing for individual patients A weakness is the lack of an established classification in day-to-day primary care in a different way than the policy system for health problems and related interventions. makers originally intended. The two groups, a) acute/minor time limited conditions Comprehensiveness, continuity, and person-centredness and interventions and b) chronic stable conditions with are essential to better health outcomes in PHC. Close and a risk for future complications, may be defined differ- trusting relationships with GPs and nurses who know ently. What the groups include or exclude is not clearly their patients are critical for a well-functioning PHC [19]. specified. To make the groups as well-defined as pos- There is ample evidence that continuity of care in PHC sible, we included only typical conditions. contributes both to better quality of care and better out- Comparison of estimated values on an ordinal scale comes [36,37]. Early detection and prevention of problems can cause problems. First, the scales are subjective and are facilitated. Furthermore, episodes of care that begin different persons may interpret them differently, which with visits to an individual’s primary care clinician, as can make comparisons hazardous. Second, there is a opposed to other sources of care, are associated with sig- tendency to avoid using the ends of the scales in nificantly lower costs [38]. Arvidsson et al. BMC Family Practice 2012, 13:114 Page 7 of 8 http://www.biomedcentral.com/1471-2296/13/114 Also, single consultations for minor problems might Authors’ contributions EA, MA, LB and PC planned the study. EA conducted the first analysis in yield high patient benefit and cost-effectiveness in the dialogue with all in the research group. DA made the statistical analysis and long term and might therefore be acknowledged by the calculations. All authors performed the final analysis, and were involved in GPs and nurses. On the other hand, there is a risk that drafting the manuscript as well as the final approval of the manuscript. the adaptation of priority setting to the patients’ demands, rather than needs, might influence consump- Acknowledgements tion and funding of health care in an unfair and ineffi- We want to thank FORSS (Council for Research in Southeast Sweden) for funding, and the county councils of Jönköping, Kalmar, and Östergötland, cient way [19]. Without a well-functioning system for and the Faculty of Health Sciences, Linköping University, for supporting the priority setting there is a risk that preventive care for study. We also thank each of the patients, nurses, and GPs who participated chronic conditions with few overt symptoms gets forced in this study. out in favour of minor self-limiting problems. In recent Author details years, the Swedish government has focused on accessi- Department of Medical and Health Sciences, National Centre for Priority bility in health care. National figures are presented regu- Setting in Health Care, Linköping University, Linköping, Sweden. Department of Primary Health Care, County Council of Kalmar, Kalmar, larly on the number of days patients must wait for an Sweden. Department of Public Health and Caring Sciences - Family appointment in primary care. Trends indicate that the Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden. number of visits are increasing and waiting times are de- Department of Medical and Health Sciences, Family Medicine, Linköping University, Linköping, Sweden. Department of Management and creasing. This, in combination with the new Swedish Engineering, Division of Economics, Linköping University, Linköping, Sweden. funding system for primary care – where patients direct and redirect funds by their choice of PHCC – might Received: 17 May 2012 Accepted: 15 November 2012 Published: 26 November 2012 make prioritising according to ethical principles difficult. For instance, a study indicated that waiting-time guaran- tees led health care providers to give priority to access References rather than needs for care [39]. 1. Carlsson P: Priority setting in health care: Swedish efforts and experiences. Scand J Public Health 2010, 38(6):561–564. The challenge for primary care providers is to balance 2. 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Published: Nov 26, 2012

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